A case report of fordyce granules with leukoplakia: Ectopia with leukoplakia

INTRODUCTION

Leukoplakia is a potentially malignant disorder that is associated with the use of tobacco in all forms but predominately with the habit of smoking. Leukoplakia usually presents clinically as white patches which have varied clinical appearances which can be deceptive at times and a biopsy is mandatory as the treatment of these lesions are based on the presence or absence of dysplasia in the histopathology report.

This article presents an interesting case report of patient with Leukoplakia with no evidence of Fordyce granules clinically, however, seen histologically.

CASE REPORT

A 47-year-old male patient reported to the Department of Oral Medicine and Radiology with chief complaint of white discoloration on the right cheek that developed few weeks back. Patient’s history revealed of habit of chewing tobacco for the past 4 years. Intraoral examination had shown a diffuse white patch approximately 6 × 5 cm in size on the buccal mucosa as shown in Figure 1. The lesion was non tender and not scrapable. Based on history and clinical findings a provisional diagnosis of leukoplakia was given. For confirmatory diagnosis, a punch biopsy was done and sent for histological diagnosis to the department of Oral Pathology and Oral Microbiology.

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Figure 1:

White patch on the right buccal mucosa along the occlusal plane.

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The histopathological features of the lesion had shown hyperplastic parakeratinized stratified squamous epithelium exhibiting pseudoepithelial hyperplasia in many areas. Dysplastic features were also observed such as broad and flat rete pegs with basal cell hyperplasia, acanthosis, cellular pleomorphism, and nuclear changes of hyperchromatic nuclei with increased nucleus cytoplasmic ratio. These dysplastic features were evident in the lower two-thirds of the thickness of the epithelium. The underlying connective tissue was loose and fibrillar with blood vessels and inflammatory cells suggestive of moderate epithelial dysplasia that were compatible with clinical features of leukoplakia as shown in Figure 2. Another finding was the presence of multiple glandular structures in the connective tissue adjacent to the overlying epithelium. The morphology of cells and arrangement were consistent of sebaceous glands which is shown in Figure 3.

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Figure 2:

(a) Microscopic section of leukoplakia (H&E 10x), (b) inlet (H&E 40x).

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Figure 3:

(a and b) Microscopic section of ectopic sebaceous glands (H&E 10x) inlet showing ectopic sebaceous follicle (H&E 40x).

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DISCUSSION

Leukoplakia is defined by WHO^[1,2] as “a white plaque of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer”. Chronic smoking, pipe smoking or tobacco chewing, irritation from the sharp teeth, ill-fitting dentures or crowns, UV radiations are some of the causes of leukoplakia. Sites of predilection are lateral and ventral tongue, floor of the mouth, alveolar ridge mucosa, and buccal mucosa, corner of the mouth, lip, and soft palate rarely. Clinically, the lesion is marked by unusual looking patches inside the mouth which is sensitive to touch, heat, spicy food, or other irritations. Fordyce granules^[3] which is not a disease but rather a developmental anomaly of the oral mucosa, is characterized by heterotopic collections of sebaceous glands at various sites in the oral cavity. Clinically, these granules appear as small yellow spots either discretely separated or forming relatively large plaques. These are most commonly found on the buccal mucosa and also in inner surfaces of the lips. Sebaceous glands are present in the oral mucosa in approximately 80% of the population. There is no specific treatment required for this condition unless esthetics is the main concern.

The present case is an interesting report of a patient who had a large diffuse white patch on the buccal mucosa but did not show the presence of Fordyce granules. It was interesting to note the presence of lobules of sebaceous cells beneath the epithelium with a central duct communicating the surface. These cells were polygonal with centrally located nucleus and abundant foamy cytoplasm. These features of Fordyce granules were appreciated only in the histopathological examination but not seen in the oral cavity. The absence of such typical yellow spots on the buccal mucosa could probably be due to thick whitish grey mucosa that could have masked the yellow spots and hence not making it clinically evident.

CONCLUSION

Fordyce granules are developmental anomaly of ectopic sebaceous glands that are seen at times in the oral cavity usually in the buccal mucosa. The present case was unique that at times, even with careful and thorough clinical examination, lesions such as leukoplakia, can mask an underlying anomaly which only ascertains the importance of histological diagnosis in the specialty of oral pathology.